Premenstrual Syndromes : PMS and PMDD - Rutuja :: The site ...

16 THE PREMENSTRUAL SYNDROMES
● The nature and clusters of symptoms are quite consistent
from cycle to cycle within individual women,
although the severity may fluctuate. 39
● Individual women may tend to present with similar
symptoms at other times of physical, psychosocial,
or hormonal stress.
● The rate of treatment response to any currently
approved medication for PMDD (currently only
selective serotonin reuptake inhibitors (SSRIs)) is
barely 20% better than placebo. 40 One may suggest
that only a subgroup of women with PMS respond to
these medications. Subgroups with other vulnerabilities
may respond to treatment modalities. 41
The suggested diversified genotypes and phenotypes
lead to a need to de-emphasize the descriptive approach
to PMS and to replace it with a generalized approach that
has already been partly adopted by ACOG. Accordingly,
the following diagnostic criteria for PMS have been
proposed, 33,42 but they are not widely accepted:
● Any mood, behavioral or physical symptom(s), or
cluster(s) of symptoms that occur recurrently and cyclically
during the luteal phase of the menstrual cycle.
● The symptom(s) remit(s) shortly following the
beginning of menses and consistently do not exist
for at least 1 week of the follicular phase of most
menstrual cycles.
● The symptom(s) cause emotional or physical distress
and/or suffering and/or impairment in daily
functioning, and/or impairment in relationships.
● The recurrence, cyclicity, and timing of the cycle,
and severity of the symptoms as well as existence of
a menstrually related symptom-free period are documented
by daily monitoring and/or reports.
Whether or not exclusively premenstrually repeated
episodes of any disorder may be considered as PMS or a
catamenial disorder is a matter of definition. This may be
addressed as part of the differential diagnosis of PMS
(see Table 2.5).
Indeed, as is the case with many mental or physical
entities, there is a debate between ‘splitters’ (those who
are searching for specific phenotypes or subgroups of
patients with very specific and narrow clinical and etiological
common denominators and similarities) and
‘lumpers’ (those who prefer a broader clinical approach
and are convinced that the differences between the
various subgroups and phenotypes are overpowered
by the similarities within the larger group). Although
I believe that there are multiple premenstrual syndromes
with different vulnerabilities and phenotypes
but a common trigger, this debate has not been
resolved yet.
Similarly, there is no consensus on the role of catamenial
episodes (see Table 2.4) as menstrually related
disorders (MRDs) and their relation with PMS. If the
definition of PMS is based mostly on timing and not on
descriptive phenomena, and if genotypes and dynamically
evolving vulnerability 35,42,43 contribute to specific
phenotypes of PMS, then one may argue that catamenial
episodes appearing during the premenstrual period are
subtypes of PMS (as long as they do not appear during
other times during the cycle). If the catamenial episodes
consistently appear at other times (non-premenstrual
phase of the menstrual cycle, e.g. periovulatory), then
they are a part of the broader definition of MRD.
As is the case with subtypes or phenotypes of PMS,
this is not just a heuristic discussion. It has direct clinical
treatment implications. In the case of catamenial
episodes, treatment should involve the disorder-specific
intervention as well as suppression of hormonal cyclicity.
This may also be the case with specific phenotypes
of PMS.
The diagnostic concept of multiple premenstrual syndromes,
as opposed to a single PMS, was not accepted
by about half of the members of the international interdisciplinary
consensus panel 44 (consensus was considered
when at least 14/16 participants agreed).
The panel agreed that a PMS ICD diagnostic code
should be incorporated in a new ‘Interdisciplinary diagnoses’
section and the title should be PMS – Premenstrual
Syndrome (different patterns of symptoms or clusters
of symptoms may appear as part of the syndrome).
The panel achieved a consensus on the pivotal role of
timing as a crucial criterion of PMS and settled on
‘2 weeks before menses in most menstrual cycles’, as
well as ‘remit following onset of menses’. Prospective
documentation of cyclicity is required, by clinician
and/or daily monitoring by the patient.
The panel required that the symptoms are not just an
exacerbation or worsening of another mental or physical
chronic disorder, and recommended issues for field
trials that are quite similar to the ones that will be
described later. These field trails require quantification
of the diagnostic criteria that were also recommended
by the panel.
RESEARCH DIAGNOSTIC CRITERIA
FOR PMS/PMDD
Owing to the vagueness on severity and other definitions
of the DSM-IV PMDD, quantitative replicable
definitions and procedures for diagnosis and outcome
measures had to be developed – to be translated into
inclusion and exclusion criteria for enrollment of patients
in clinical trials.